http://www.ijwhr.net doi 10.15296/ijwhr.2019.

76

Open Access Original Article

International Journal of Women’s Health and Reproduction Sciences
Vol. 7, No. 4, October 2019, 461–466
ISSN 2330- 4456

Effect of Pelvic Rocking Exercise Using the Birth Ball on

Fetal Lie, Attitude, and Presentation
ID ID
Supriatiningsih1 , Herlina2, Lusia Asih Wulandari3, Sri Nowo Retno3, Mohammad Kanedi4*

Abstract
Objectives: For decades, scholars have debated the benefits of exercise during pregnancy. Birthing ball exercise is the latest among
the antenatal exercises which pregnant women commonly perform in Indonesia. Therefore, the current study aimed to investigate
whether pelvic rocking exercise using the birth ball is effective in correcting the fetal lie, presentation, and attitude in the late third
trimester of pregnancy.
Materials and Methods: To this end, pregnant women (n=114) enjoying the inclusion criteria were randomly divided into
intervention (who were assigned to perform pelvic rocking using the birth ball) and control (without exercise) groups. Fetal lie,
attitude, and presentation before and after the trials were determined in both groups by performing the abdominal palpation of
Leopold’s maneuver.
Results: Based on the results, the intervention group showed a higher proportion of fetus with flexed attitude (P < 0.001) as compared
to the control group. In addition, 49.1% of women in the intervention group indicated longitudinal lie compared to 29.8% of those in
the control groups (P < 0.001). Finally, 56 out of 57 women in the intervention group demonstrated head presentation whereas only
45 out of 57 women in the control group showed the same presentation (P < 0.01).
Conclusions: Overall, it is suggested that pelvic rocking exercises using the birth balls are useful for maintaining lies, fetal attitudes,
and presentations and thus it is worth recommending for pregnant women.
Keywords: Pregnancy exercise, Pelvic rocking, Birthing ball, Fetal presentation

Introduction response (8). Reports from Indonesia show that passenger

Maternal mortality ratio (MMR) in Indonesia is the
highest among countries in the South Eastern Asian
Region (1) and prolonged labor is among the factors
which are contributed to such a high MMR (2). The 2012
Indonesia Demographic Health Survey findings revealed
that among 14 782 birth numbers, 34.7% of the mothers
experience prolonged labor, and at least 0.8% of the cases
end with maternal deaths (3). In addition, compared to
the prevalence of prolonged labor on average (one-fifth
of women), the prevalence of the cases in Indonesia is
higher (4).
Prolonged labor often causes serious consequences
for both mother and infant. For mothers, it can lead
to maternal exhaustion and dehydration, along with
severe postpartum hemorrhage (5) while in infants,
it can decrease the score of Apgar (i.e., appearance,
pulse, grimace, activity, and respiration) scale whereas
increasing the asphyxia incidence (6). Considering the
adverse consequences, taking into account the treatment
and management of prolonged labor are of great
importance (7).
Several factors affect labor and delivery, including
fetal size, the size and shape of maternal pelvis, uterine
contraction forces, maternal position, and maternal psyche
(fetus) is the most frequent among these prolonged labor-
related factors. A study performed in Kalimantan Selatan
(South Borneo) during 1995-1996 also indicated that the
passenger (64%) was the most important factor which was
related to 72 prolonged labor cases (9). The findings of
another study conducted in Lampung province revealed
that among the prolonged labor cases, 39.2% were related
to fetal malposition and presentation and 37.2% belonged
to fetal macrosomia (10).
With regard to the fetal malposition and malpresentation,
the question arises regarding whether there is any method
that birthing mothers and/or care providers can employ to
correct the abnormality. Among others, the use of antenatal
exercises is present for facilitating the fetus to rotate from
the occiput posterior position to a favorable occiput
anterior presentation (11). Maternal postural techniques
are also suggested for encouraging and attaining the best
cephalic version of the baby’s head to enter maternal pelvis
(12). The overall benefits of pregnancy exercise include
shorter labor, less preterm labor, less complications, and
decreased hospital stay (13).
In this regard, birthing ball exercise is considered as the
most recent method among the antenatal exercises which
pregnant women prevalently perform in Indonesia. So far,

Received 13 March 2018, Accepted 2 November 2018, Available online 7 January 2019
1
Department of Midwifery, MoH Health Polytechnic of Tanjung Karang, Lampung, Indonesia. 2Azizah Hospital, Kota Metro, Lampung, Indonesia.
3
Midwifery Academy of Patriot Bangsa Husada, Lampung Tengah, Lampung, Indonesia. 4Department of Biology, Faculty of Mathematics and
Sciences, University of Lampung, Bandar Lampung, Indonesia.
*Corresponding Author: Mohammad Kanedi, Email: wegayendi@yahoo.com
Supriatiningsih et al
several studies have reported the benefits of pregnancy
exercise using a birthing ball, including managing pain
mainly the back pain, as well as decreasing stress and
anxiety levels, the pethidine usage in labour wards, and
cesarean section rate (14-16). Furthermore, the women in
labor not only can manage to cope with the labor pain and
progress but also attain self-control and more satisfactory
birthing experience when the birth ball is used to perform
pelvic rocking (17).
Further, the exercise may allegedly affect fetal-
positioning in utero if pelvic rocking exercise with a
birth ball is considered useful for reducing the pain,
increasing the labor progress, and making the birthing
experience more satisfactory. Given the above-mentioned
explanations, the present study sought to evaluate whether
the pelvic rocking exercise using the birth ball contributes
to correcting the fetal position from transverse or oblique
to longitudinal, the fetal presentation from the breech or
the shoulder to head, and fetal attitude from the deflexed
to flexed posture in the late third trimester of pregnancy.
Materials and Methods
Participants and Study Design
The research targeted pregnant females living in the
territory of three community health centers (Pusat
Kesehatan Masyarakat) in the district of Kota Metro,
Lampung, namely, Yosomulyo, Margorejo, and dan
Karangrejo. A quota sampling technique was applied
to select the research subjects who had the following
inclusion criteria:
1. Showing singleton pregnancy;
2. Being at or more than 29 weeks of gestation;
3. Willing to sign the informed consent;
4. Willing to perform pelvic rocking;
5. Representing no sign of pelvic disorder;
6. Having no bleeding during pregnancy;
7. Demonstrating no fetal malposition.
Otherwise, the subjects were considered ineligible.
Finally, 114 pregnant women were included in the study
and were randomly classified into intervention (assigned
to perform pelvic rocking using the birth ball) and control
(without exercise) groups. The baseline of fetal position
in both groups was determined by performing the
abdominal palpation of Leopold’s maneuver immediately
upon receiving the informed consent.
Interventions
The employed birthing balls were the Kettler Gym Ball
with a diameter of 65 cm. Five well-trained midwives
provided the instructions to mothers regarding pelvic
rocking exercises using the birth ball. The exercises
included 5 steps as follows:
• Sitting straddle on the ball;
• Rocking the pelvis forward and backward with
shoulder still 4 times;
• Rocking the pelvis to the left and right side with
462 International Journal of Women’s Health and Reproduction Sciences, Vol. 7, No. 4, October 2019
shoulder still 4 times;
• Rotating the hips clockwise then anti-clockwise 4
times;
• Swaying the hips in a figure-eight pattern four times.
All women in the intervention group performed
the exercises weekly for 3 weeks and then, by using a
questionnaire, they were asked to report whether they
correctly performed the exercises. At the end of the
program, mothers of both groups were evaluated for the
fetal position using the abdominal palpation of Leopold’s
maneuver.
Fetal Assessment
The four performed Leopold’s maneuvers in the abdominal
palpation were as follows:
The first and the second maneuvers were performed
to determine the presenting part at the fundus and
the fetal back, respectively. Moreover, the third and
the fourth maneuvers were performed to identify the
position and mobility of the presenting part and the
fetal descent, respectively. The evaluated variables were
fetal lie, presentation, and attitude. The fetal lie is either
longitudinal, transverse, or oblique and fetal presentation
is distinguished into the head, breech, or shoulder whereas
fetal attitude is either of flexed or deflexed posture.
Data Analysis
Both descriptive and inferential statistics from SPSS
software, version 22.0 were applied in the data analysis.
The descriptive statistics were used to depict the general
characteristic of the research subjects while inferential
statistics (the chi-square test) were performed to compare
the subjects with and without pelvic rocking exercise. The
limit of statistical significance was P<0.05.
Results
Characteristics of the Subjects
Characteristics including age, education, gravidity, and the
fetal position of both intervention and control groups are
presented in Table 1. With regard to age, the majority of
women of both groups (57.9% and 59.6% in intervention
and control groups, respectively) aged over 31 years. As
regards the education level, there was a difference between
the two groups. Similarly, most women in the intervention
group (62.3%) had upper secondary education while
those in the control group had mostly (50.9%) primary
education. In terms of gravidity, the majority of women
in both groups (70.2% and 59.6% in intervention and
control groups, respectively) had multigravida (two
or more pregnancies). Furthermore, based on the pre-
trial assessments of the fetal position (baseline), it was
ascertained that the fetal attitude, lie, and presentation were
normal in both groups. Additionally, 70.3% and 71.9% of
patients in intervention and control groups were flexed in
terms of the fetal attitude, respectively. Incidentally, both
groups showed the same proportion of fetal lie including
Supriatiningsih et al

Table 1. General and Baseline Characteristics of Intervention and Control significantly (P < 0.001) leads to the flexed attitude of the
Groups
fetus in comparison to the control group (35.1%).
Intervention Control Based on the data and statistical test results in Table 3,
Characteristics
No. % No. % the pelvic rocking also showed a significant contribution
Age 57 100 57 100 to correcting the fetal lie so that 49.1% of women in the
≤ 20 years 1 1.8 6 10.5 intervention group indicated longitudinal lie compared to
21-30 years 23 40.4 17 29.8 29.8% of those in the control group (P < 0.001).
≥ 31 years 33 57.9 34 59.6 Furthermore, the data and statistical test results in Table
Education 57 100 57 100 4 represent that pelvic rocking exercises with the birth ball
Primary 17 29.8 29 50.9 play a role in normalizing the fetal presentations. In the
Secondary 31 54.5 18 31.6 intervention group, 56 out of 57 subjects demonstrated
Higher education 9 15.8 10 17.5 the head presentation whereas only 45 out of 57 of them
Gravidity 57 100 57 100 in the control group that indicated the head presentation
Primigravida 14 24.6 10 17.5 (P < 0.01).
Multigravida 40 70.2 34 59.6
Grande multigravida 3 5.3 13 22.8 Discussion
Fetal attitude 57 100 57 100 Based on the data presented in Table 1, the participant
Flexed 40 70.2 41 71.9 characteristics of both intervention and control groups
Deflexed 17 29.8 16 28.1 were balanced except for the level of education. The
Fetal lie 57 100 57 100 secondary or higher education levels (70.3%) of women
Longitudinal 33 57.8 33 57.8 in the intervention group is a probable explanation for
Oblique 22 38.6 22 38.6 their willingness to follow the pelvic rocking. As was
Transverse 2 3.6 2 3.6 scientifically suggested, further education leads to more
Fetal presentation 57 100 57 100 knowledge, capability, and awareness of individuals
Head 50 87.8 45 78.9 regarding adopting a healthy lifestyle and maintaining
Breech 6 10.6 3 5.3 their physical health including performing exercises (18).
Shoulder 1 1.8 9 15.8
Considering the data in Tables 2, 3, and 4, pelvic rocking
with a birth ball should be emphasized and recommended
in antenatal care during pregnancy. Nevertheless, the
the longitudinal, oblique, and transverse lies of 57.8%, controversy about the benefits of pregnancy exercises on
38.6%, and 3.6%, respectively. Eventually, respecting fetal prolonged labor is not inevitable. As it is known, during the
presentation, 87.8% of women in the intervention group 1960s, there has been a debate about the value of exercise
and 78.9% of them in the control group indicated a normal during labor. Although it is doubtful that exercise during
presentation (head presentation). pregnancy is extremely beneficial in shortening the birth
process, it can reduce the structural burden experienced
Trial Effects by the mother in pregnancy and labor in addition to
Tables 2, 3, and 4 provide the fetal attitude, lie, and reducing the back pain and improving the abdominal
presentation of the intervention and control groups after posture and pelvis muscle. Pelvic shaking exercises alone
three-week clinical trials, respectively. As shown in Table are considered useless in improving the pelvic capacity,
1, the pelvic rocking exercise using the birth ball (50%) though they are only beneficial in reducing the back

Table 2. Fetal Attitude of Intervention and Control Groups

Fetal Attitude
Total
Trials Flexed Deflexed
No. (%) No. % No. %
Intervention 57 (50) 57 50.0 0 0.0
Control 57 (50) 40 35.1 17 14.9
Total 114 (100) 97 85.1 17 14.9
Chi-Square Tests
  Value df Asymp. Sig. (2-sided) Exact Sig. (2-sided) Exact Sig. (1-sided)
Pearson Chi-square 19.979a 1 0.000 0.000
Continuity correctionb 17.698 1 0.000
0.000
Likelihood ratio 26.562 1 0.000
Linear-by-linear association 19.804 1 0.000
No. of valid casesb 114        
a
Zero cells (0%) have an expected count less than five and the minimum expected count is 8.50; Computed only for a 2x2 table.
b

International Journal of Women’s Health and Reproduction Sciences, Vol. 7, No. 4, October 2019 463
Supriatiningsih et al

Table 3. Fetal Lie of Intervention and Control Groups

Fetal Lie
Total
Trials Longitudinal Oblique Transverse
No. % No. % No. % No. %
Intervention 57 50 56 49.1 0 0 1 0.9
Control 57 50 34 29.8 22 19.3 1 0.9
Total 114 100 90 78.9 22 19.3 2 1.8
Chi-Square Tests
  Value df Asymp. Sig. (2-sided) Exact Sig. (2-sided) Exact Sig. (1-sided)
Pearson chi-square 27.378a 2 0.000 0.000
Likelihood ratio 35.931 2 0.000 0.000
0.000
Fishers exact test 32.570     0.000
Linear-by-linear association 19.931b 1 0.000 0.000
No. of valid cases 114
a
Two cells (33.3%) have an expected count less than five and the minimum expected count is 1.00; b The standardized statistic is 4.464.

Table 4. Fetal Presentation of Intervention and Control Groups

Fetal Presentation
Total
Trials Head Breech Shoulder
No. % No. % No. % No. %
Intervention 57 50 56 49.1 0 0 1 0.9
Control 57 50 45 39.5 4 3.5 8 7.0
Total 114 100 101 88.6 4 3.5 9 7.9
Chi-Square Tests
  Value df Asymp. Sig. (2-sided) Exact Sig. (2-sided) Exact Sig. (1-sided)
Pearson Chi-square 10.642a 2 0.005 0.002
Likelihood ratio 12.943 2 0.002 0.004
0.001
Fishers exact test 10.330 0.004
Linear-by-linear association 8.982b 1 0.003 0.003
No. of valid cases 114
a
Four cells (66.7%) have an expected count less than five and the minimum expected count is 2.00; b The standardized statistic is 2.997.

pain (19). is thought to encourage the placenta to produce more

Later and toward the third millennium, the benefits of
exercise during pregnancy received attention once more.
Some of the benefits of pregnancy exercise are as follows:
• Minimizing the weight gain by reducing body fat
accumulation;
• Minimizing backache;
• Reducing pregnancy discomfort;
• Maximizing the ability to manage breathing and
relaxation;
• Reducing stress and increasing the self-confidence;
• Minimizing labor complications;
• Accelerating postpartum recovery.
Based on the study results of a study on the efficacy
of pregnancy exercises, body movement in the exercise
can enhance cardiovascular capacity and increase muscle
strength, elasticity, and extensibility (20), which is in line
with the results of the current study.
In addition, based on the findings of another study
regarding testing the efficacy of moxibustion as the
traditional Chinese medicine in labor, the improved fetal
positions were suspected to be associated with uterine
muscle contractions (21). The practice of moxibustion
estrogen, enhance the production of prostaglandin
that affects the uterus contraction leading to a higher
probability of optimal fetal positioning, and finally,
facilitate the fetal movements (22).
Despite its long history of invention, the use of the
birth ball, originally called the Swiss ball, advocated in
pregnancy exercise. The findings of the current study
confirm the benefits of exercise with the birth ball during
pregnancy, which corroborates with the findings of many
previous studies. The pelvic rocking exercise and birthing
ball were revealed to be useful in shortening the labor
process and empowering mothers during the labor in
addition to be effective in managing the lower back pain
during pregnancy (23,24). Likewise, the physical exercises
performed during pregnancy between the second and
third trimesters are reported to be beneficial in reducing
the labor duration of the first stage and the possibility of
cesarean operation (25).
The recent reviews of prenatal care practices show that
physical activity during pregnancy is still highly promoted
regardless of the type of exercise since it is of great
benefit to maternal and infant health during the peri and

464 International Journal of Women’s Health and Reproduction Sciences, Vol. 7, No. 4, October 2019
Supriatiningsih et al
postnatal period. (26). Further, physical activities during
pregnancy play a role in assisting the mothers’ locomotor
system in adapting to mother’s biomechanics that might
arise from weight gain during pregnancy (27). Based on
the reports, aerobic exercise performed 3-4 times a week
for 35-90 minutes significantly associates with a lower
frequency of cesarean operation and a high incidence of
vaginal births (28). Thus, these findings provide a basis
for assuming that exercise during pregnancy is useful in
facilitating labor.
Conclusions
In general, the present study applied the pelvic rocking
exercise using the birth ball based on the abdominal
palpation using four Leopold’s maneuvers and the results
confirmed the success of such exercise in maintaining and
promoting normal lies, fetal attitudes, and presentations.
Thus, pelvic rocking exercises by the birth ball are highly
recommended for pregnant women.
Conflict of Interests
Authors declare that they have no conflict of interests.
Ethical Issues
The informed consent form was confirmed by the Ethics
Commission of the Midwifery Program and authorized
by the Director of MoH Health Polytechnic of Tanjung
Karang, Lampung, Indonesia through a decree No:
LB.01.02/11/0117/ 2017.
Acknowledgments
The authors are grateful for the Research Grant from the
Board for the Development and Empowerment Human
Resource of Health, the Ministry of the Health Republic
of Indonesia.
References
1. Analen C. Saving mother’s lives in rural Indonesia. Bull
World Health Organ. 2007;85(10):740-741. doi:10.2471/
BLT.07.031007
2. Rahayu HSE. Mother’s experience in managing labor pain
in central java Indonesia. Int J Res Med Sci. 2017;5(7):3012-
3017. doi:10.18203/2320-6012.ijrms20172979
3. Statistics Indonesia (Badan Pusat Statistik—BPS), National
Population and Family Planning Board (BKKBN), and
Kementerian Kesehatan (Kemenkes—MOH), and ICF
International. 2013. Indonesia Demographic and Health
Survey 2012. Jakarta, Indonesia: BPS, BKKBN, Kemenkes,
and ICF International; 2012. https://dhsprogram.com/
pubs/pdf/fr275/fr275.pdf.
4. Nystedt A, Hildingsson I. Diverse definitions of prolonged
labour and its consequences with sometimes subsequent
inappropriate treatment. BMC Pregnancy Childbirth.
2014;14:233. doi:10.1186/1471-2393-14-233
5. Nyfløt LT, Stray-Pedersen B, Forsén L, Vangen S. Duration
of labor and the risk of severe postpartum hemorrhage:
A case-control study. PLoS One. 2017;12(4):e0175306.
International Journal of Women’s Health and Reproduction Sciences, Vol. 7, No. 4, October 2019
doi:10.1371/journal.pone.0175306
6. Li WH, Zhang HY, Ling Y, Jin S. Effect of prolonged second
stage of labor on maternal and neonatal outcomes. Asian
Pac J Trop Med. 2011;4(5):409-411. doi:10.1016/s1995-
7645(11)60114-4
7. Ali A, Masakhwe BA. WHO midwifery education module
3: Managing prolonged and obstructed labour. Paper
presented at: Training Course in Sexual and Reproductive
Health Research 2010. Geneva Foundation for Medical
Education and Research; 2010 Jul 18. http://www.gfmer.
ch/SRH-Course-2010/assignments/Managing-prolonged-
obstructed-labour-Ali-Masakhwe-2010.htm.
8. Guidelines for Maternal Care in South Africa: A manual
for clinics, community health centres and district hospitals.
National Department of Health, Republic of South Africa.
https://www.health-e.org.za/wp-content/uploads/2015/11/
Maternal-Care-Guidelines-2015_FINAL-21.7.15.pdf.
9. Ronsmans C, Achadi E, Cohen S, Zazri A. Women’s recall
of obstetric complications in south Kalimantan, Indonesia.
Stud Fam Plann. 1997;28(3):203-214.
10. Yohanna WS. Analisis Faktor-Faktor yang Berhubungan
dengan Persalinan Lama. J Aisyah. 2016;1(1):33-46.
11. Sutton J, Scott P. Understanding and teaching optimal
foetal positioning. 2nd ed. Tauranga, New Zealand: Birth
Concepts; 1996. p. 69.
12. Guittier MJ, Othenin-Girard V, Irion O, Boulvain M.
Maternal positioning to correct occipito-posterior fetal
position in labour: a randomised controlled trial. BMC
Pregnancy Childbirth. 2014;14(1):83. doi:10.1186/1471-
2393-14-83
13. May LE. Effects of Maternal Exercise on Labor and
Delivery. In: May LE, ed. Physiology of Prenatal Exercise
and Fetal Development. Boston, MA: Springer; 2012.
doi:10.1007/978-1-4614-3408-5_2.
14. Hau WL, Tsang SL, Kwan W, et al. The use of birth ball
as a method of pain management in labour. Hong Kong J
Gynaecol Obstet Midwifery. 2012;12(1):63-68.
15. Leung RW, Li JF, Leung MK, et al. Efficacy of birth ball
exercises on labour pain management. Hong Kong Med J.
2013;19(5):393-399. doi:10.12809/hkmj133921
16. Mirzakhani K, Hejazinia Z, Golmakani N, Sardar MA,
Shakeri MT. The effect of birth ball exercises during
pregnancy on mode of delivery in primiparous women.
J Midwifery Reproductive Health. 2015;3(1):269-275.
doi:10.22038/jmrh.2015.3562
17. Zaky NH. Effect of pelvic rocking exercise using sitting
position on birth ball during the first stage of labor on its
progress. IOSR Journal of Nursing and Health Science.
2016;5(4):19-27. doi:10.9790/1959-0504031927
18. Zimmerman E, Woolf SH. Understanding the relationship
between education and health (Discussion Paper).
Washington, DC: Institute of Medicine; 2014.
19. Blankfield A. The value of exercises in obstetrics. Aust
J Physiother. 1966;12(2):51-54. doi:10.1016/S0004-
9514(14)60960-0
20. Hammer RL, Perkins J, Parr R. Exercise during the
childbearing year. J Perinat Educ. 2000;9(1):1-14.
doi:10.1624/105812400x87455
21. Cardini F, Weixin H. Moxibustion for correction of
breech presentation: a randomized controlled trial. Jama.
465
Supriatiningsih et al

1998;280(18):1580-1584. doi:10.1001/jama.280.18.1580 2017;22:36-42. doi:10.1016/j.hsag.2016.08.004

22. Zhang QH, Yue JH, Liu M, et al. Moxibustion for the
correction of nonvertex presentation: a systematic review
and meta-analysis of randomized controlled trials. Evid
Based Complement Alternat Med. 2013;2013:241027.
doi:10.1155/2013/241027
23. Elkheshen SA, Mohamed HS, Abdelgawad HA. The
Effect of Practicing Pelvic Rocking Exercise on Lowering
Disability Level through Decreasing Pregnancy Related
Lower Back Pain. J Am Sci. 2016;12(5):98-103. doi:10.7537/
marsjas12051612
24. James S, Hudek M. Experiences of South African
multiparous labouring women using the birthing ball
to encourage vaginal births. Health SA Gesondheid.
25. Garland M. Physical activity during pregnancy: a
prescription for improved perinatal outcomes. J Nurse
Pract. 2017;13(1):54-58. doi:10.1016/j.nurpra.2016.07.005
26. Stefani L, Mascherini G, Galanti G. Indications to Promote
Physical Activity during Pregnancy. J Funct Morphol
Kinesiol. 2017;2(3):31. doi:10.3390/jfmk2030031
27. Di Mascio D, Magro-Malosso ER, Saccone G, Marhefka
GD, Berghella V. Exercise during pregnancy in normal-
weight women and risk of preterm birth: a systematic
review and meta-analysis of randomized controlled trials.
Am J Obstet Gynecol. 2016;215(5):561-571. doi:10.1016/j.
ajog.2016.06.014

© 2019 The Author (s); This is an open-access article distributed under the terms of the Creative Commons Attribution License
(http://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, and reproduction in any medium,
provided the original work is properly cited.

466 International Journal of Women’s Health and Reproduction Sciences, Vol. 7, No. 4, October 2019